Acute biologic crisis By: TMREVILLE Drowning & Near drowningDefinition Drowning: Death due to submersion in liquid (usually water) Near Drowning: is survival for more than 24 hours from suffocation by submersion.Common complication: hypoxemia Classes of drowning Dry: laryngospasm →water doesn’t enter the lungsWet: laryngospasm relaxes→ water enters the lungsTypes of Drowning Active Drowning: vertical in water, not kicking, still breathing and usually moving the arms Passive Drowning Causes

Attempted suicide Blows to the head or seizures while in the

water Drinking alcohol while boating or

swimming Falling through thin ice Inability to swim or panicking while

swimming Leaving small children unattended

around bathtubs and pools Summary of the drowning process:

1. Panic & violent struggle 2. Period of Calmness 3. Swallowing of fluid (vomiting) 4. Terminal Gasp 5. Unconsciousness 6. Seizures 7. Death

Pathophysiology: prolonged submersion in water→ decrease in metabolic demands/diving reflex/mammalian reflex→ successful resuscitation with full neurologic recovery→ hypoxia, hypercabia, acidosis→ cerebral injury, ARDS, pulmonary damage, cardiac arrest

Freshwater drowning: loss of surfactantSaltwater drowning: pulmonary edema (osmosis) Therapeutic goals: maintaining cerebral perfusion, adequate oxygenation (prevent further damage to vital organs)Immediate CPR-greatest influence on survivalThe treatment goal: prevention of hypoxia

serial vital signs ensure an adequate airway &

respiration(ventilation) ABGs (determine the type of ventilatory

support needed) Supplemental O2, by mask ET intubation w/ +P

o improves oxygenationo Prevents aspirationo corrects intrapulmonary

shunting o corrects Ventilation–perfusion

abnormalities (caused by aspiration of water)

N/I: hypothermia

o rectal probeo rewarming procedures

(extracorporeal warming,o warmed peritoneal dialysis,

aerosolized O2, torso warming) hypotension and impaired tissue

perfusion: Intravascular volume expansion & inotropic agents

dysrhythmias: ECG monitoring compromised renal function: indwelling

urinary catheter decompress the stomach & prevent the

patient from aspirating gastric contents: NG intubation

Teaching Children to Swim Drowning rescue, throw assist: if the water is too deep or dangerous to enter or victim is too far out to reach with a long object, a throwing assist may be wisest

Drowning rescue, board assist: if the water is calm and shallow enough (no higher than chest) you can get into the water to reach the victimDrowning rescue, reaching assist: if the victim is in deep or dangerous water but there is a dock to stand on, try a reaching assist with a long, sturdy objectDrowning rescue on ice, board assist: if a person falls through ice, do not go onto ice to attempt a rescue. From a safe place try a reaching assist with a long, sturdy objectDrowning rescue on the ice, human chain: if a person falls through ice and there is more than one person on solid ground, form a chain of bodies from a secure location out to the fallen personINJECTED POISONS: STINGING INSECTS Hymenoptera allergy

extreme sensitivity to the venoms of : bees, hornets, yellow jackets, fire ants & wasps

Venom allergy –IgE Clinical manifestations range

o generalized urticariao Malaiseo laryngeal edema o severe bronchospasm o shock, and death.

Management stinger removal:venom is assoc. /sacs

around the barb of the stinger Wound care w/ soap and water Scratching is avoided because (results in

histamine response. Ice application (reduces swelling &

decreases venom absorption) oral antihistamine & analgesic (itching

and pain) Severe allergic response: Epinephrine (aqueous), SC, massaged to hasten absorption. SNAKE BITES

1 -9 y.o. high risk daylight hrs. to early evening(summer)

pit vipers

Management Initial first aid: Let victim lie down Remove constrictive items Provide warmth cleanse the wound cover w/ a light sterile dressing immobilize the injured body part below

the level of the heart. Do not apply: Ice or a tourniquet

Initial evaluation: Whether the snake was venomous or

non-venomous if the snake is dead, it should be

transported to the ED with the pt for ID1 Where and when the bite occurred Circumstances of the bite Sequence of events S & Sx (fang punctures, pain, edema, and

erythema of the bite and nearby tissues) Severity of poisonous effects V/s Circumference of the bitten extremity or

area at several Points (compare w/ the other extremity) Laboratory data (CBC, UA & clotting

studies)Management

Do not use during the acute stage (first 6 to 8 hrs): ice, tourniquets, heparin, Corticosteroids are contraindicated in after the bite: may depress antibody production, hinder the action of antivenin

For hypotension: Parenteral fluids & vasopressors (short-term)

Surgical exploration of the bite Pt. is observed closely for at least 6 hours

: Never leave unattended ANTIVENIN (ANTITOXIN)

antitoxin manufactured from the snake venom

admin. w/n 12 hours after the snake bite Children may require more dose Skin test 15 mins. before & after: the

circumference of the affected part is measured proximally

Premedicate w/: diphenhydramine and cimetidine

IV (slow), IM diluted in 500 -1000 mL of NSS

total dose :infused during the first 4-6 hrs after poisoning

ANAPHYLACTIC REACTION an acute systemic hypersensitivity

reaction that occurs within seconds or minutes after exposure to certain foreign substances

result of an antigen–Ig interaction in a sensitized individual who, as a consequence of previous exposure, has developed a special type of Ig that is specific for that particular allergen.

fullness in the face, urticaria, pruritus, malaise, and apprehension→ tachycardia, SOB, hypotension, and shock → stop: Diphenhydramine, vasopressors, E cart (standby)

Management establishing a patent airway & ventilation administer epinephrine

Early ET intubation is essential (to avoid loss of the airway)

oropharyngeal suction (remove excessive secretions)

Resuscitative measures (pts with stridor and progressive pulmonary edema)

O2 therapy Pharmacologic management• Antihistamines: to block further histamine binding at target cells• Aminophyllin: slow intravenous infusion for severe bronchospasm and wheezing refractory to other treatment• Albuterol inhalers or humidified treatments: to decrease bronchoconstriction;crystalloids, colloids, or vasopressors; to treat prolonged hypotension• Isoproterenol or dopamine: for reduced cardiac output• Intravenous benzodiazepines: control of seizures; corticosteroids f; for prolonged reaction with persistent hypotension or bronchospasm Poisoning Poison: any substance that, when ingested, inhaled, absorbed, applied to the skin, or produced w/n the body in relatively small amounts, injures the body by its chemical action. Pesticide poisoning

INGESTED (SWALLOWED) POISONS Emergency Tx goals: • To remove or inactivate the poison before it is absorbed• To provide supportive care in maintaining vital organ systems• To administer a specific antidote to neutralize a specific poison• To implement treatment that hastens the elimination of the absorbed poison Corrosive poisons include

alkaline and acid agents

cause tissue destruction after coming in contact with mucous membranes

o drain cleanerso toilet bowl cleanerso Bleacho detergentso oven cleanerso button batteries o metal cleanerso Rust removerso battery acid

Shock, may result from: cardiodepressant action of the substance

ingested venous pooling in lower extremities reduced circulating blood volume

(increased capillary permeability)ASSESSMENT

determine what substance was taken; the amount; time since ingestion; signs and symptoms, such as pain or

burning sensations any evidence of redness or burn in the

mouth or throat, pain on swallowing inability to swallow, vomiting, or drooling; age and weight of the patient; Pertinent health history.

Management Control of the airway, ventilation, and

oxygenation are essential. (-) cerebral or renal damage, patient’s

prognosis depends largely on successful management of respiration and circulation.

ECG, vital signs, and neurologic status An indwelling urinary catheter is inserted

to monitor renal function. Blood specimens are obtained to test for

concentration of drug or poison. The patient who has ingested a corrosive

poison is given water or milk dilution is

not attempted if the patient has acute airway edema or obstruction, esophageal, gastric, or intestinal burn or perforation.

The following gastric emptying procedures may be used as Prescribed:

Syrup of ipecac (induce vomiting) Gastric lavage for the obtunded patient Gastric aspirate –send to the laboratory

for testing(toxicology screens) Activated charcoal ADMIN. Cathartic, when appropriate

Antidote The specific chemical or physiologic

antagonist; administer as early as possible(to reverse or diminish the effects of the toxin)

If these measures are ineffective, procedures are initiated to remove the ingested subs. such as:

o Administer of multiple doses of charcoal

o diuresis (for substances excreted by the kidneys)

o Dialysiso Hemoperfusion: detoxification

of the blood by processing it through an extracorporeal circuit and an adsorbent cartridge containing charcoal or resin, after which the cleaned blood is returned to the patient.

Carbon monoxide poisoning CO2 High Hgb affinity: 250x stronger than O2Carboxyhemoglobin: CO–bound Hgb, Doesn’t transport O2

Goals of management: to reverse cerebral and myocardial

hypoxia hasten elimination of carbon monoxide. Whenever a patient inhales a poison, the

following general measures apply:• Carry the patient to fresh air

immediately; open all doors & windows.

• Loosen all tight clothing.• Initiate CPR if required;

Administer oxygen.• Prevent chilling; wrap the

patient in blankets.

• Keep the patient as quiet as possible.

• Do not give alcohol in any form. 100% oxygen is administered at

atmospheric or hyperbaric pressures: to reverse hypoxia,To accelerate the elimination of carbon monoxide.

O2 is admin. until the carboxyhemoglobin level <5%.

Symptoms of permanent brain damage Psychoses Spastic paralysis Ataxia visual disturbances deterioration of mental status and

behaviorHemorrhage

results in the reduction of circulating blood volume is

a primary cause of shock. fluid volume deficit decreased cardiac output

Management

Direct, firm pressure is applied over the bleeding area or the involved artery

Firm pressure dressing is applied, and the injured part is elevated (to stop venous & capillary bleeding if possible)

Immobilize AFFECTED extremity to control blood loss.

Tourniquets: last resort when the external hemorrhage cannot be controlled in any other way.; Applied just proximal to the wound and tied tightly enough to control arterial blood flow.; Periodically, the tourniquet is loosened (to prevent irreparable vascular or neurologic damage.); For arterial bleeding, the tourniquet is removed and a pressure dressing is applied.; For traumatic amputation with uncontrollable hemorrhage, the tourniquet remains in place until the patient is in the OR

Replacement fluids may include: isotonic electrolyte solutions (LR, NSS),

colloid, and blood component therapy: platelets and clotting factors

Packed RBCs are infused when there is massive blood loss. In emergencies: O-negative blood is used for women of childbearing age and O-positive blood is used for men & postmenopausal women

ABG (evaluate pulmonary function and tissue perfusion and to establish baseline hemodynamic parameters): index for determining the amount of fluid replacement the patient can tolerate and the response to therapy.

supine position and monitored closely Hypovolemic Shock: a condition in which there is loss of effective circulating blood volume. Inadequate organ and tissue perfusion follow,

ultimately resulting in cellular metabolic derangements.Nrsg. Dx.:

Altered tissue perfusion related to failing circulation

Impaired gas exchange related to a ventilation–perfusion imbalance

Decreased cardiac output related to decreased circulating blood volume

*In the event of acute hemorrhaging (internal bleeding), the venous blood, the blood volume and consequently cardiac output are reduced, and progresses inevitably to inadequate tissue perfusion and cardiocirculatory arrest and death.*Hypovolemic shock is a severe and acute metabolic disturbance caused by a reduction in volume of blood as from hemorrhage or dehydration. Blood loss from the vascular system

reduces the volume of venous blood returning to the heart.Goals of treatment: to restore and maintain tissue perfusion and to correct physiologic abnormalities.Large-gauge IV needles or catheters are inserted into peripheral veins.

Two or more catheters are necessary for rapid fluid replacement & reversal of hemodynamic instability.

emphasis : volume replacementManagement

indwelling urinary catheter is inserted Serial Hct values Place the victim in shock position Keep the person warm and comfortable Turn the victim’s head to one side if neck

injury is not suspectedCentral venous pressure (CVP) catheter

Inserted (in or near the right atrium) to serve as a guide for fluid replacement.

Continuous CVP readings give the direction & degree of change from baseline readings.

The catheter is also a vehicle for emergency fluid volume replacement.

Infusion of LR (approximates plasma electrolyte composition & osmolality)

Seizures

the result of a sudden disruption of orderly communication among nerve cells in the brain, called neurons.

can lead to a number of symptoms, which vary depending on where the disruption occurs in the brain and where the abnormal electrical activity spreads.

1. simple partial seizures: finger or hand may shake, mouth may jerk uncontrollably, person may talk unintelligibly, may be dizzy, and may experience unusual or unpleasant sights, sounds, odors, or tastes, but without loss of consciousness 2. complex partial seizures: the person either remains motionless or moves automatically but inappropriately for time and place, he or she may experience excessive emotions of fear, anger, elation, or irritability. Whatever the manifestations,

the person does not remember the episode when it is over. 3. Generalized seizures/grand mal seizures: intense rigidity of the entire body may occur, followed by alternating muscle relaxation and

contraction (generalized tonic–clonic contraction), simultaneous contractions of the diaphragm and chest muscles may produce a characteristic epileptic cry, tongue is often chewed, and the patient is incontinent of urine and feces. After 1 or 2 minutes: convulsive movements begin to subside; patient relaxes and lies in deep coma, breathing noisily. Respirations at this point are chiefly abdominal. Postictal state: patient is often confused and hard to arouse and may sleep for hours. May report headache, sore muscles, fatigue, and depression.

Tonic-clonic seizures Absence seizures Atonic seizures : "drop attack," atonic seizures cause a sudden loss of muscle tone. ; may result in the dropping of the head or a limb, or lead a student to fall to the ground.; There also may be a brief loss of consciousness. Myoclonic seizures

typically affecting children and young adults.

involves a sudden contraction of muscles and can appear as a jerk of one or both arms or sometimes the head.

may cause just a single jerk or several jerking movements.

seizure is so brief that although the pt. loses consciousness, he or she may appear conscious.